Treating Anxious Kids—Part II: How Much Zoloft?

A recent study published in the New England Journal of Medicine found Zoloft and cognitive behavioral therapy to be highly effective in the treatment of reasonably severe anxiety disorders in children and adolescents. I reported on the findings when they first appeared, hailing them as mostly good news, and promised to come back with further postings about the limitations of the research.

The Journal is selective when it comes to research studies in psychiatry. I suspect that the editors chose this paper because it looked at a large sample (489 subjects) and because the results were striking. The children had social anxiety, generalized anxiety, and separation anxiety. On medication, most kids responded, and the responses were substantial. The combination of medication and psychotherapy was particularly effective.

But it pays to read these studies in detail - I suppose that's a prime theme of this blog: the devil is in the data.

Here, the medication doses were high. In adults, the standard Zoloft dose for depression is 50 mg daily. A number of patients in my practice have done well on 25 mg. To treat anxiety, the starting doses tend to be low; at first, antidepressants can increase anxiety. But for unknown reasons, the final dose, to mitigate anxiety, can be substantial. The package insert sets the daily dosage range for obsessive-compulsive disorder, post-traumatic stress disorder, and social anxiety disorder at 50 to 200 mg. Again, in my clinical experience, for the more routine forms of anxiety often modest doses suffice.

But in the current study of anxiety in children, the average Zoloft dose was between 133 and 146 mg daily. The children started at 25 mg, with the dose raised weekly as needed up to the eighth week of the study. Effectively, the number of pills must have been increased on almost every visit. By comparison, the placebo group got to pills resembling 176 mg, on average - so the active drug was being raised almost as fast as a pill that did nothing. (In this case, obviously, it did not even help through buoying expectations - that's why doctors kept adding pills.)

The average age of children in the study was under 11 years. According to data from the Centers for Disease Control, the average 11-year-old boy carries about half the weight of an average 20-year-old man; with girls and women, the ratio is about 60 per cent. This sample had about equal numbers of boys and girls. If we assume that Zoloft distributes throughout the body, the children were taking a Zoloft dose equivalent to over 250 mg daily for an adult. So what the study seems to show is that, in children, if you use medication to pound the hell out of anxiety, it remits.

But it is not at all clear that it would be prudent to keep children on this sort of regimen. We have enough concerns about the hidden effects of chronic medication use on the developing brain. Surely it is worrisome to administer Zoloft to children at levels beyond what we are familiar with in adults.

To test the drug, the scientists designing the trial obviously thought it necessary to raise doses quickly. It just is too expensive to conduct a study where you behave as clinicians do in practice, giving a small dose and waiting for an effect, and then trying a small increase, and so on. The researchers write, "The schedule that we used, which emphasized upward dose adjustment in the absence of response and adverse events, suggests that the average end-point dose of sertraline [ie, Zoloft] in this study is the highest dose consistent with good outcome and tolerability."

Probably, if child psychiatrists can afford to be patient, it will turn out that lower antidepressant doses work fine for anxiety in children. But we don't know as much from this study. It may be that only very high doses work - and whether children can safely be left on those doses is also entirely unknown.

So a fuller account of this research's findings would say that Zoloft, particularly in conjunction with psychotherapy, is remarkably effective for anxiety disorders in children and adolescents - but at drug doses that may not be prudent. Further research will be needed to test the safety of the regimen under study. (Apparently a six-month follow-up is in progress - which is a start.) And only new, more expensive trials can tell us whether medication works at more modest doses, equivalent to what the field has been prescribing for adults.

In a future posting, I will explore the limitations of the psychotherapy arm of this same study.

These studies target anxious children but are they not most probably children who have moderate to severe depression,that will one day have chronic depression ? I assume these children are challenging to the point of making family life unbearable.Is it only when they reach adulthood and really create mayhem do we then call it depression,and not anxiety? The question seems to be,what kind of children are being treated? If they are depressives then it seems they must be treated out of their delusional world back into reality. Who can make such a call? It's as if their future bad deeds will help define their condition and victims await their day.I'm being way too melancholic here, on a lighter note,have you tasted the CRUNCH CRISP wafer bars by NESTLE,very yummy!

I'm a non-medical therapist but I've worked with many patients who've been prescribed medications, often at my urging them to do so.

I applaud your sharing the wisdom of the effectiveness of lower doses. I continually see patients over-medicated, particularly with SSRI's. I've found many people reach a therapeutic dosage at 25mg of zoloft.

Also, I've seen teenagers treated with 50 mg and more of zoloft who've had violent reactions, not consistent with their character and potentially very dangerous. At the higher doses the medication has to be stopped when this problem occurs, yet it could easily be avoided by waiting and seeing what the lower dosage will do.

I agree lowest dose possible. HOWEVERi have a very big problem with a ny child under 18 or even 20 being on ANY brain chemical , mind altering drug, this is critical issue, children's brains are growing& developing its own set. Of hormones& balance of brain chemicals during this time& when you introduce a fake lab created chemical you are interfering with that process& their brains ha ve no hope of growing normally because there are artificial hormones& chemicals in place .iam on the fence with holistic treatments but some have their value, even if it's not the end all. In this case I feel ANY child presenting any kind of psychiatric issue be 2st treat holistically, such as diet changes, I had a friend a few years ago with a child presenting bipolar 1 and so the meds& hospitalizations began. Finally, as she became worse & wose they sought holistic hell& 2dt did a medically supervised drug holiday&then began a holistic treatment which mainly consisted of a must follow: no cheating diet& today she is a high functioning normal adult without chemical treatment now, as for the woman whose child's dose was upped to like 150 then started having all these tics, either she's developing setatonin m( can't remember name) will look hip which can be life threatening or possibly tartodisconrsia(so?,know that's wrong) in which case tthe tics can become permanent but the smile thing concerns me, almost sounds like she's being driven into a psychosis. I would. Find another doctor & get a 2nd opinion because something is very wrong there

I'm the author of Help Is On Its Way – A Memoir About Growing Up Sensitive. I grew up with the trait of high sensitivity, but it was not discovered until I was 32. When I was a child, my parents thought I was depressed. I was very anxious because of the family's unstable circumstances. I had the trait of high sensitivity highly but nobody understood that. Thankfully it was during a time when there were no medications for anxiety.

I hope that this post will help me help parents learn about the trait of high sensitivity, so parents can understand certain anxious children and to comfort and validate these children, their feelings, and their experiences.

HIGH SENSITIVITY, EXPLAINED:

Kids with high sensitivity are born with a more keenly developed nervous system. (15-20 percent of kids have the trait of high sensitivity.) That’s 20 million children in the United States alone. Usually if a child or teen has the trait, at least one of their parents has it, too, or maybe their sisters or brothers. It is inherited.

WHAT IT LOOKS LIKE:

Below are a few sample questions that you’d answer a strong yes to if you’re highly sensitive...

* Do you get rattled under time pressure, especially during tests and when someone is watching over you?

* Do you avoid violent movies and TV shows?

* Can you easily sense other people's feelings? Do you put other people’s needs before yours?

* Do you need to withdraw during busy days to someplace where you can have privacy and relief?

* Do you go out of your way to avoid social situations you think might be upsetting or overwhelming?

* Do you have a creative and complex inner life?

* Do (did) your parents or teachers see you as sensitive or shy?

WHAT IT FEELS LIKE:

A highly sensitive child will pick up on all the subtle things going on around him/her in a magnified way. There is a strong intuition and perception present in a highly sensitive child. They can sense a lot of what’s going on around them. They can see other people’s needs and that makes them want to help make things better, but also feel overwhelmed by the largeness of that task. This makes them appear "pouty," withdrawn, anxious or depressed. They find it impossible to put their feelings into words. Sometimes, as teens, they can get tangled up in trying to fix other people’s problems that they neglect their own basic needs, which heightens the anxiety even more.

However, when highly sensitive kids are exposed to people who encourage their deep feelings and natural tendencies, these kids absolutely shine. They gain confidence and develop solid, healthy boundaries. They're very creative, visionary, and conscientious by nature.

HELPFUL RESOURCES FOR LEARNING MORE:

A great book to start with for highly sensitive children teens or adults is The Highly Sensitive Person or The Highly Sensitive Child by Elaine Aron, because they help readers identify and understand this trait of sensitivity. Teens with more difficult backgrounds might benefit by reading my coming-of-age memoir, Help Is On Its Way. Dr. Elaine Aron has endorsed this book.

I lived with high anxiety for decades because I was told who I was was wrong and I didn't understand why my feelings were so big compared to others. I wrote my coming of age story to help kids and teens feel more understood. This book puts high anxiety into words and allows parents, teachers, counselors, guardians and others see the big picture of what is affecting the child.

When reading your questions, I could answer a strong 'yes' to all but maybe one of them. I'd never heard of high sensitivity. I now have a 3-year-old daughter who has been diagnosed with anxiety and compulsive tendencies. She's on Guanfacine, which hasn't been as effective as we'd like. So her Dr. prescribed Sertraline. We have not yet given it...wanted to learn more about it first. I'd be willing to give it if it would truly help and not harm my child. My husband is adamantly against it because he has taken it in the past and remembers feeling horrible. After reading this article, it certainly raises concerns. The behavior I'm concerned with in my daughter is that she, on several occasions, has sought out a smaller child and has aggressively hit, pulled hair, pushed, or injured him/her without being provoked. I don't know where this comes from. I've responded with scolding and spanking, but she continues to do it if she has the opportunity. I'm at my wit's end and am tempted to start her on Sertraline, but I wonder what else can be done first. What is the psychotherapy that could benefit her? She seems to have some of the other sensitivity traits, extreme shyness, but not sensitivity to others' feelings. HELP!

Hi,I used to work in this field many years ago.iam not a doctor or therapist but was a behavioral assistant for a psychology department.i also have a 6yr old grandson who my husband and i are raising.he has been diagnosed with high level ADHD& now anxiety,today they prescribed zoloft &i dont want to give it to him,however,he does wake several times a night with nightmares or concerns or crying,so we have to do something.i read your story &when I got to the last few sentences ,including the part where she doesn't care about others feelings or the harm she causes,along with other things you mentioned,my 1st thought was,she is misdiagnosed,&has Aspbergers or another mild form of autism.have the doctors you see ever explored the possibility?like i said,am not a professional &also dont have all her information,was just a thought

I hate seeing kids put on meds but understand they may in some cases, be needed. My grandson is on th guanfacine & a cpl mo ago they added a quickly graduated dosage regimen.almost immediately he became angrier& angrier& then started acting out. Had to be put at desk alone in school& he's only 7.we have a strong history of bipolar disorder in our family & one thing I learned the hard way( with my son)& then asking docs who would tell the truth& not be bought by a pharmaceutical company.(I find it disturbing to hear a person around every corner tell me their child has been put on Zoloft) that you NEVER give anyone, child or adult an antidepressant without a moodstabilizer if they have a history of bipolar.my son was put on Effexor , started it on a Friday& was hospitalized for 11 days for a severe manic episode.it triggered the onset of his latent bipolar1 disorder. It happens. And the folks treating our children know it can happen. It's hard for them because diagnosing children is tricky business. Correctly anyway.and nobody knows the damage it can do to developing brains. Best I could say to you is know your family history& research what you're being given

My 7 year old grandson became increasingly aggressive on Zoloft, had to wean him off it. Had to pull him out of tae kwon doe when he started threatening strangers with it.they hv put him on a mood stabilizer with almost zero side effects, very safe... Lamotrigine.

I couldn't agree with you more! I agree with you 100 percent ! Thank you for sharing your story and finding. I commend you!
I feel that children need a lot of love and understanding. They have a voice that needs to be heard. This is a long subject matter and there are so many variables and things to consider and every case is different, but above all I firmly believe that you are correct. I have been saying the same thing as you, parents need to start off my being open to listening to their children and consider all their thought and concerns and feelings. Be open minded with you heart and soul to see things through their perspective, through their eyes and seek professional counseling if need be.
Love them and listen with all your heart, . Take things one step at a time before you consider putting your child these harsh behavior altering drug like Zoloft you'd be surprised at the results. After all we only want the best for our beautiful children's lives and we want them to have positive life experiences that will last a lifetime!.. etc.

Much love and peace to all and may god be with you. I wish you all much continued success. Always tell your children how much you love them !

My 11 year old has all these signs, she has many health issues and has been diagnosed ptsd, her sister passed away from cystic fibrosis 4 years ago and this is one of the things he fights every day. they have also said she has social anxiety, social phobia, and ocd. she is afraid of most people and never draws attention to herself. thy are starting her on Zoloft on Monday, I just hope it helps her.

What state do you live in? With everything you describe, I would try whatever form of medical marijuana before I tried a commercial medicine. It quickly& effectively treats all those thoughts& behaviors you described

My 12 year old daughter has ALWAYS be super sensitive. We could tell early on that she was much more anxious than our other children. Even as a baby to much noise or action going on would throw her into a crying fit that was almost unstoppable. When she became a toddler she had overly emotional reactions to both separation and again to much action. Once she started 1st grade things seemed to go very well until 4th grade (those girl hormones started everything over again!) After 14 months of council ling and behavior redirection we gave into Zolof -- best fricken 15.00 co-pay EVER! She is happier and able to control her emotions. We still continue with a bi-monthly therapy visit, but she is so much happier and in control of herself now. I hope that we will be able to move off of this drug, but for the hormone blasting next few years we will stay with it! She even understands what it helps her with and says she is glad that it helps her think things threw with out just crying about everything. Do what it best for your child and help them how you can, trust me when I say drug were not the way we wanted to go but she is happier and my child's happiness is my main concern!

Thank you so much for posting! My son is almost 10. At 4 he was diagnosed with sensory disorder and at 7 with anxiety disorder with OCD tendencies. Finally at 9 1/2 our pediatrician agreed to try a medication regime. (We have done counciling for three years to no avail) We started on Welbutrin but after 3 weeks my poor son broke out in severe hives. Next stop...Zoloft. I cried when the Doc said it and could still cry now. I have heard nothing but negative about zoloft and am so very scared to put it into my sons body. After reading your post, I took a sigh of relief knowing that there is someone else out there using it and they are O.K. I hate to watch my son suffer in his anxiety and emotional distress...I hope that we too will see our true son shine through with this medicine! Thank you again for posting and best of luck to you and your daughter!

Just started my 10year old son on Zoloft after much thought and felt he needed relief from his anxiety and obsessive thoughts. Marci what dosage does your daughter take? Curious. Son started with 25mg which seemed to be working slowly but they raised it by half a dosage and now he says he gets bouts of anger and irritated. I'm going to go back to his original dose.

@Nikki: You have just described my 10 year old daughter! How is the Zoloft going? We have tried EVERYTHING which has taken her personality away and she's currently on nothing. Sensory-YES! Broke her arm and didn't cry. Anxiety-Yes..very fidgety, etc. OCD Tendencies-Heck yes!!! (unfortunately). She's a very bright and well rounded child but slips into what I call her "other personality"...considering Zoloft before she makes me up my dose!!!

I will say, after years of my son (who is now almost 12) dryheaving in the bathroom or in the back seat of my car and crying all the way into school, I was at wits end. If we walked into a restaurant and it smelled strongly of anything, he would start dryheaving. One year at school they even had to let him take his lunch into the office as he would throw up from the smell in the cafeteria. He knew that he had a supersensitive stomach and would throw up and was anxious about being embarrassed. Before walking out of the door to go to anywhere, at home, he would lock himself into the bathroom and run the shower to try to 'gather' himself. Once out and on the way to wherever it was we were going-he would ask what was wrong with him. It was absolutly heartbreaking. He is a very outgoing child. Has plenty of friends, does average in school. He is just VERY anxious. Since first starting school, his first week always was me physically carrying him into class, him puking, crying, etc. He made quite the first impressions every year to say the least. I am one of those moms that does NOT like to medicate her child. But after seeking Psychiatric help, it was suggested to start him on Zoloft. I sat there and cried. The doctor told me that I would see a new child almost immediately. I was certainly skeptical. Within two days of taking his Zoloft, he was happy, not nervous, and functioning in school once again. He has now been on Zoloft for one year and I couldnt be happier. He is on 50 mg at present. This seems to work perfectly for him, but as he gets a bit of maturity in him, I plan to scale back to 25mg and see if he can learn to cope a bit better on his own.

My 12 yr old daughter was on 50mg zoloft for anxiety for several years and it was increased to 100mg as her weight increased and some signs of anxiety were present again. It helped her anxiety. She developed an anger attitude last year. Now her mom, an RN, has asked the doc for more again but this time saying its for depression. The doc said if still a problem in a month, then he'd increase. He boosted the dose to 150mg. I noticed her ear was red and a bit swollen a few times. Her eyes dart side to side some times and she grins some, replying that she does not know why. I expect it will cause unknown long term problems while helping some too. I wonder if the problem the boost to 150mg is treating may have been caused by the 100mg dose of zoloft. I would have preferred trying a dose reduction from 100mg to 50mg instead of a boost to 150mg. She's been at 150mg a few days. Will ask dr about going back to 100mg in light of observed side effects and lack of long term safety study results at high doses.
Engineer Dad

I would be very worried about long term effects if that were my daughter. Have you checked into her diet and ran some blood work to see if can be treated in a more holistic manner??? That would be my first instinct. Good luck.. I know it's not easy..

Fastin is a true "mood promoter" whose stimulant effects are
rapid, yet exceptionally even throughout each dose.

Weight loss design includes increased lipolysis (fat loss) accompanied by elevated
mood and high-energy levels in combination with a reduced caloric intake and
increased metabolic expenditure typical of an effective overall weight loss plan.We love
inspiring our followers and fans, whether it’s on facebook,
pinterest or twitter, and we especially like to hear.
It’s Friday again! How has your weight loss journey been going this last week?
Great, we hope! The side effects of phentermine, like lack of sleep
and low mood, as well as pushing yourself to exercise. As well as setting the goals you want to achieve and planning
out how you will approach each of the weight loss stages.
Since we know that weight loss is a journey (we’ve been there, too!), we have developed a series of tools to help you
reach your goal! Weight loss tools to lose more pounds. Lose weight,
Celebrate your success! Phentemine.com has helped thousands of people
lose weight! We offer FREE weight loss tools and supportive online community!
Get inspired by the success of our users by checking out our 90+ success stories, by people just like YOU!
Adipex (sometimes known as Adipex-P) is the most popular brand of phentermine diet pills, manufactured by Teva Pharmaceuticals USA.
It is a phentermine 37.5 mg dosage (the strongest) that you can buy
in capsule or tablet form. Adipex is not cheap phentermine.
It is generally considered high quality. Phentermine 37.5 mg is a very popular dosage of phentermine.
Popular dosages include 15mg, 30 mg and 37.5 mg. All manufacturers of phentermine diet pills have their
own 37.5 mg dosage. Phentermine 37.5 mg tablets or capsules are generally cheap
and are manufactured by generic pharmaceutical groups.
Qsymia (previously known as Qnexa) is a new diet pill combo made of phentermine and Topiramate.
It was approved by the FDA in 2012 and recently launched in September 2012.
Because it uses phentermine as an appetite suppressant, it is considered as a very effective
diet pill but cannot be prescribed to everybody.

Phen Caps are an alternative to the prescription drug,
phentermine. Phen Caps give similar benefits as phentermine, such as supressing
appetite, stimulating your metabolism and increasing energy, without the side effects.

Phen Caps do not contain phentermine, making them available without a prescription to anyone.

Dr. During this period of time I was atheistic. In the aftermath of recent NSA leaks, the companies set aside their competitive differences to come together and urge Obama to curtail the NSA's online snooping and lift restrictions that prevent companies from publicly disclosing specifics about how frequently they are asked to turn over their users' personal information in the name of national security.
black infrared 6s http://www.iso-tec.com/UserFiles/File/blackinfrared6s/index.html

My son, at 13, was put on Zoloft: first 25, then 50, then 75 mg. At that point he had to go in-pt., although he told us later that it started a few weeks after the first dose. He had visual, auditory and tactile hallucinations. My gifted son developed Psychosis NOS that lasted until he was almost 20. He had to take Lithium and high doses of Seroquel, Clonidine, etc. to approach being a normal person.

He lost his teen years to mental illness. I can't express the extreme turmoil in our home and the suffering for all four of us. He was better off mildly depressed!

I urge anyone prescribing Zoloft to children and teens to reconsider. My son, in his 20's, is working and normal again. But he has some post traumatic stress from those years.

I was 15 when I was put on Zoloft for anxiety and depression. In the space of about 2 months I gained 50 pounds. The weight gain was so dramatic I came within an inch of developing type 2 diabetes. Once my psychiatrist realized the connection he took me off it and prescribed something else (I don't remember what) I lost the weight and avoided diabetes. I would strongly suggest that no kid ever be put on Zoloft, there are much better options out there.